Breastfeeding:

Good For Babies, Mothers and the Planet

Alicia Dermer, M.D., I.B.C.L.C.
Anne Montgomery, M.D.

Human Milk's Nutritional Benefits

Human milk, the best food for babies, contains the right amount of nutrients, in the right proportions,
for the growing baby. A living, biological fluid, it contains many unique components. For example,
lactoferrin provides optimal absorption of iron and protects the gut from harmful bacteria; lipases
assist in digestion of fats; and special growth factors and hormones contribute to optimal growth and
development. Mother's own milk changes during a feeding from thirst-quenching to
hunger-satisfying, and comes in a variety of flavors as mother's diet varies. Its composition changes
as the baby grows to meet baby's changing nutritional needs. It serves as the nutritional model for
artificial baby milks, but none of these can match it.

While most people are aware that human milk provides excellent nutrition, many people are unaware
of breastfeeding's other health benefits for babies.

Breastfeeding and the Immune System

Human milk is baby's first immunization. It provides antibodies which protect baby from many
common respiratory and intestinal diseases, and also contains living immune cells. First milk,
colostrum, is packed with components which increase immunity and protect the newborn's intestines.
Artificially fed babies have higher rates of middle ear infections, pneumonia, and cases of
gastroenteritis (stomach flu). Breastfeeding as an infant also provides protection from developing
immune system cancers such as lymphoma, bowel diseases such as Crohn's disease and celiac
sprue, and juvenile rheumatoid arthritis, all of which are related to immune system function. And
breastfed babies generally mount a more effective response to childhood immunizations. In all these
cases, benefits begin immediately, and increase with increasing duration of breastfeeding.

Babies from families with a tendency to allergic diseases particularly benefit from breastfeeding.
Exclusive breastfeeding, especially if it continues for at least six months, provides protection against
allergies, asthma, and eczema.

Infant Growth and Development

New growth charts from the World Health Organization confirm that breastfed infants grow
differently from formula fed babies. Breastfed infants grow faster initially, then slow down as they
approach their first birthday.(This can sometimes be interpreted as "dropping off the growth curve,"
but really represents normal growth.) People artificially fed as infants go on to have a higher risk of
obesity as adults.

More and more research is showing that breastfeeding leads to optimal brain development. While
there are behavioral aspects to this, the milk is important, too. One study of premature babies who
were tube-fed breast milk or artificial milk, but were never breastfed directly, showed that the babies
who received no breast milk had IQS 8 points lower on average than those who received breast
milk. Human milk has special ingredients like DHA (docosohexaenoic acid) and AA (arachidonic
acid) which contribute to brain and retinal development. And all breastfed babies tend to spend a lot
of their time in the "quiet alert" state which is most conducive to learning.

Breastfeeding in Special Circumstances

Breastfeeding has other special benefits for premature infants. Premature breastmilk contains
different amounts of some nutrients than term breastmilk, more suited to the needs of premature
babies. Necrotizing Enterocolitis, a serious bowel inflammation, is very rare for breastfed infants.
And of course they get the same immune protection, which may be even more critical for
prematures, and has been shown to reduce the risk of sepsis in these babies. Suckling at the breast,
and digesting breast milk, cause less stress for the premature infant than bottle-feeding does; so most
prematures can go to breast as soon as they are able to suckle. Because of the reduction in
infections and the shorter time to full feeding, breastfed premature infants can usually leave the NICU
sooner. For some babies, breastfeeding is a life-and-death matter. In addition to its known benefit
where water supplies are unsafe or food supplies erratic, breastfeeding lowers the risk of SIDS in all
populations.

There are very few reasons, particularly from the baby's point of view, to avoid breastfeeding. Most
authorities recommend that USA mothers who are HIV positive not breastfeed; however, in many
areas of the world breastfeeding's known benefits outweigh the small risk of transmission from breast
milk. Few other medical conditions preclude breastfeeding, as there are many appropriate
medications that are suitable for use in breastfeeding moms.

Breastfeeding's immunologic and developmental benefits may be particularly important for babies
with medical problems such as congenital heart disease, cleft palate, Down's syndrome, etc. In cases
where the baby has a problem which affects ability to suckle at the breast, expressed breast milk
from mother is still the best choice. Banked human milk, the availability of which is unfortunately
limited, would be the second choice. Commercial artificial baby milks are preferable to other
alternatives, but far from perfect substitutes for human milk. For every "new" component that is
added to commercial baby milks to make them closer to human milk, several more components of
human milk are discovered.

It's not JUST the milk, either!

In addition to all the known benefits of human milk, it's also clear that the act of breastfeeding is
beneficial. Breastfeeding's contribution to optimal oral development means less risk of malocclusion
-- and perhaps lower orthodontist bills! Bottle-fed babies have a higher risk of baby bottle tooth
decay, as well. Close skin-to-skin contact with mother provides optimal nurturing and an almost
automatic close emotional attachment. Suckling at breast optimizes hand-to-eye coordination,
especially with regular "side-switching." Even in the rare cases when mother can't produce enough
milk, or for adopted babies, supplemental systems can allow mother and baby to enjoy a
breastfeeding relationship.

Breastfeeding and Women's Health

The extent to which breastfeeding affects mothers' health is rarely emphasized. Much of the lay
literature about breastfeeding makes it sound like a rather time-consuming, difficult and even painful
experience that women must endure for the sake of their babies' health. No wonder some mothers
are left with the impression that they must "martyr" themselves and breastfeed for their baby's sake.

Surprise: Breastfeeding is good for mothers, too! Not only that, but it is a joyful, relaxing experience.
Although breastfeeding advocates have been criticized for oversimplifying and not informing mothers
of potential problems of breastfeeding, the truth of the matter is that when practiced optimally
breastfeeding is an enjoyable experience, pure and simple. We must remember that many of the
problems and inconveniences so commonly described in the lay literature and passed around by
word of mouth as "horror stories" are due to the fact that we live in a bottle-feeding society, with
little family or social support and little understanding of breastfeeding by many health care
professionals. Thus, problems such as "insufficient milk syndrome," engorgement, cracked and
bleeding nipples, all of which would be rare in a breastfeeding society, have become commonplace.

Physical Health Benefits for Mothers

First of all, it almost goes without saying, but what's good for babies is good for mothers. In other
words, healthier babies are less stressful to care for, and the decreased medical costs are a boon to
the family. Furthermore, the optimal neurological and intellectual development provide potential
long-term benefits to the family.

In addition, there are many direct health benefits to breastfeeding mothers. Immediately after birth,
repeated bursts of oxytocin released in response to the baby's sucking cause contraction of the
uterus. This protects mothers from postpartum hemorrhage (bottle-feeding mothers get oxytocin
intravenously immediately after birth, but for the next 24-48 hours during which risk of hemorrhage is
highest, they're on their own). Continued exclusive nursing (i.e., breastfeeding without added bottles
of formula or solids) tends to delay the return of ovulation and menstruation. In fact, the lactational
amenorrhea method (LAM) is a well-studied method of child spacing which is 99% effective in
preventing pregnancy in the first six months as long as exclusive nursing is practiced. For mothers
who don't practice exclusive breastfeeding, there is still some relative protection; and most
contraceptives including barrier methods, IUD's and even progesterone-only hormonal
contraceptives such as the "mini-pill" or injectable "depo" progesterone, are all compatible with
breastfeeding. So there's no need to stop breastfeeding in order to use effective birth control.

In addition to the child-spacing advantage,
the delayed menses also decrease the
mother's iron losses. When combined with
improved iron absorption from the gut, the
net effect (despite some iron use for
breastmilk production) is decreased risk of
iron deficiency anemia.

Another well-documented benefit of
breastfeeding is more rapid and sustained
weight loss. Milk production uses up
200-500 calories a day. To burn off an
equivalent number of calories, a
bottle-feeding mother would need to swim
30 laps or ride a bicycle for over an hour. In our opinion, breastfeeding is definitely easier! Mothers
who have had gestational diabetes benefit particularly from the efficient use of calories during
breastfeeding, since a return to optimal weight may prevent subsequent development of diabetes.
Furthermore, diabetic mothers who breastfeed tend to need less insulin or medication for their
diabetes.

The prolonged suppression of ovulatory cycles appears to be associated with significant long-term
health advantages as well. Mothers who breastfeed for at least 6 months throughout their lifetime
have a decreased risk of breast cancer, and similar reduced rates have been shown for ovarian and
uterine cancers. Even being breastfed has been associated with decreased risk of breast cancer,
over and above the fact that women who were breastfed themselves are more likely to breastfeed
their own children.

For some time, there was concern about calcium loss during lactation and potential for osteoporosis.
In fact, some literature actually lists breastfeeding as a risk factor for osteoporosis. Current medical
literature demonstrates that not only is the loss in bone density during breastfeeding temporary,
reverting to normal after weaning, but that bones may actually be stronger after prolonged
breastfeeding. Far from a risk factor for osteoporosis, breastfeeding may actually protect against it.

The impact of breastfeeding on other women's illnesses needs further study. One example is the
connection between breastfeeding and cholesterol levels. Breastfeeding mothers tend to have high
total cholesterol levels, made up largely of the HDL ("good") fraction. This may prove to decrease
the risk of coronary artery disease.

Are there any known harmful effects of breastfeeding on women's health? A couple of studies have
demonstrated an increased risk of rheumatoid arthritis flare-ups and increased severity of arthritis in
nursing mothers. Whether it is breastfeeding or some other confounding factor which causes this
increase remains to be determined.

Psychosocial Issues in Breastfeeding and Women's Health

What about the emotional aspect of women's health? Where does breastfeeding fit in? Let's talk
about mother-infant bonding, a somewhat controversial subject. Much is made about the way that
breastfeeding facilitates this bonding, while at the same time it is clear that bottle-feeding mothers
usually establish deep emotional bonds with their babies. This issue is difficult to study scientifically,
but there is evidence of hormonal effects of breastfeeding which may predispose a mother to closer
bonding with her infant. Combined with the automatic skin-to-skin contact and closeness afforded
by breastfeeding (something which bottle-feeding mothers have to work to duplicate), this could
result in improved bonding. An interesting sideline from a study in a developing country found that
when breastfeeding rates were increased among mothers with a significant abandonment rate, fewer
of these mothers abandoned their babies. Other studies have suggested that there may be a lower
rate of child abuse in breastfeeding families considered to be at risk.

Another common psychological issue after birth is postpartum depression(PPD). The role of
breastfeeding in this area is not clear, with some studies showing increased rates of PPD among
breastfeeding mothers, others lower rates. The cause of PPD is unknown, and is probably due to a
number of factors, including hormonal changes and lack of support in the new overwhelming role of
motherhood. For some depressed mothers, their breastfeeding relationship takes on special
importance. Sometimes, when antidepressant medications are deemed necessary, doctors are
concerned about prescribing them for a breastfeeding mother. Antidepressants have been studied,
and some have been demonstrated not to get to the baby or cause any symptoms. The small
potential risk of the medication to the baby has to be weighed against the potential emotional
devastation to an already depressed mother of having to wean her baby, as well as the known
detrimental effects on infant emotional development when mother suffers from persistent depression.

Let's consider the situation of mothers who need to return to work. Is it worth it to breastfeed at all?
Is it necessary to wean the baby when returning to work? Is pumping and storing mother's milk
worth the effort? The answer to these questions is: yes, no and definitely. Even if a mother needs to
return to work within weeks and will be unable to pump while at work, the baby benefits from the
colostrum and early milk and mother gets the experience of the closeness and bonding. On return to
work, a breastfeeding mother has three options: continue to breastfeed exclusively by nursing while
at home and pumping her milk while at work; continue to nurse while at home and feed formula
while at work; wean completely to formula. Clearly, any amount of continued breastfeeding would
be preferable to weaning. Studies have shown that babies in day care whose mothers provide their
milk have the fewest days out of day care and their mothers have the fewest missed days from work,
while those who were breastfed and got some formula were sick more often. The mothers of
completely formula-fed babies had the most days out of work to care for their sick babies.

Although pumping and storing may sound daunting and time-consuming, most mothers whose
employers give breastfeeding support find that they work into an easy routine, and the work of
pumping is worth it for the peace of mind of a healthier child and the continued bonding from
breastfeeding on returning home. Increasing numbers of companies, in response to studies showing
economic benefits, are instituting policies supportive of continued breastfeeding for their employees.
Additionally, the cost of renting or even purchasing a pump is much lower than the cost of formula.

Breastfeeding and Fathers

So what's in it for Dad? Breastfeeding benefits fathers, too. First, and most straightforward,
breastfed babies have less offensive dirty diapers. There are no bottles to prepare and warm in the
middle of the night. Fathers benefit from having a healthy baby, and can play with, snuggle, and
bathe the baby as their relationship develops. If participating in feeding is important, he can be the
main solid-food feeder later. Dads generally also appreciate the impact on the family budget of lower
health care costs, fewer sick days, and lack of need to buy formula. And all of the health benefits for
mothers make it likely that his partner will be healthier.

Breastfeeding and The Environment

Another important issue related to infant feeding and health is the interaction between infant feeding
method and the environment. Breastfeeding is a completely natural, efficient use of resources. In
contrast, artificial feeding involves overgrazing of land by cattle; use of chemical fertilizers to grow
the soy; use of valuable environmental resources for formula production; packaging and
transportation of the product; use of water and fuel for mixing the product and heating it, for
sterilizing bottles and nipples; waste disposal of the cans, bottles, accessories, cartons, etc.

Despite this, the media and some environmental groups tend to play up issues of environmental
contaminants in mother's milk. In fact, except in situations of toxic spills or occupational exposure to
hazardous levels, breastfeeding has caused no ill effects in babies. To the contrary, studies
comparing breastfed and bottle-fed babies in the same environment have shown better development
and less cancer in the breastfed babies.

Furthermore, despite concerns about PCBs in breastmilk potentially producing infertility in the
offspring, the major burden of PCBs gets to babies during pregnancy. (Note: cows get exposed to
PCBs, too, so artificial milks are not necessarily "pure," either.) A lesser known and less publicized
issue is the fact that soy formulas contain phytoestrogens, which may have just as serious long-term
effects. Rather than calling for women to avoid breastfeeding, the call needs to be to continue to
clean up the environment to safeguard everyone's health. Breastfeeding will contribute to this
clean-up effort.

Conclusion

In light of the overwhelming evidence of breastfeeding benefits not only for babies but also for
mothers and the planet, it seems fair to say that the choice of an infant feeding method is far more
than the choice between two relatively similar methods with only convenience as the deciding factor.
When a mother chooses not to breastfeed or decides to wean early from the breast, she is not
merely substituting an inferior artificial substance without any disease-protection properties for her
child and feeding her child with an unnatural implement. She is also potentially affecting her own
immediate and long-term health in many ways. Artificial feeding increases personal and societal
health care costs, and detrimentally affects the environment.

Breastfeeding in a society where bottle-feeding is the norm clearly requires a significant commitment,
especially when relatives and friends do not support breastfeeding. However, women making the
decision about infant feeding should know that breastfeeding is clearly more than a lifestyle choice: it
is a significant health decision with life-long consequences. And, speaking from personal experience,
it's also fun!

Editor's note: Alicia Dermer, M.D., I.B.C.L.C. is Clinical Assistant Professor in the Department of
Family Medicine at the University of Medicine and Dentistry of New Jersey -- Robert Wood
Johnson Medical School. She is board certified in Family Practice.

As part of her interest in wellness and health promotion, Dr. Dermer has developed a special interest
in the area of breastfeeding education and promotion. She is active in educating health care
professionals, especially fellow physicians, in lactation. She is collaborating on the development of a
curriculum for her medical school. In 1995, she successfully passed the certifying examination of the
International Board of Lactation Consultant Examiners. She has published medical journal articles on
lactation, and lectures extensively on the subject. She may be contacted at: Alicia Dermer, MD,
IBCLC, 69 County Road 516, Old Bridge, New Jersey 08857 USA, Telephone: (908) 254-1515;
FAX: (908)651-0774, e-mail: dermer@umdnj.edu

Anne Montgomery, M.D. is a board certified family physician, and Clinical Assistant Professor in the
department of Family Practice at the University of Washington. She teaches family practice residents
and medical students at the St. Peter Hospital Family Practice residency. She is a fellow of the
American Academy of Family Physicians, a member of the Academy of Breastfeeding Medicine,
and a supporting member of the International Lactation Consultants Association. She is active in
birth and breastfeeding advocacy, and lectures frequently on these subjects.

She was in private practice for 5 years in Minnesota, after graduating from Mayo Medical School,
and completing her residency in family practice at St. John's Unit of the University of Minnesota
Community Hospital's family practice training program. Dr. Montgomery is married to Charles
Nordstrom, and the mother of Ian Montgomery Nordstrom, a breastfed baby who is now 6 years
old.